Tentative Placement Form

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Field Placement Assignment
You have been tentatively assigned to the agency listed below. It is your responsibility to call your
prospective supervisor to arrange an interview. INTERVIEWS SHOULD BE COMPLETED ASAP.
At this interview you should discuss:
1.
The range of activities which the agency can provide;
2.
What you would like to get out of field placement;
3.
Any issues related to the days and hours that the agency would require you to work.
Some agencies require flexible schedules;
4.
Agency requirements regarding liability insurance;
5.
The amount of travel required, and who pays for the gas;
6.
Your future goals/plans in social work;
7.
Anything else which comes to mind during the interview.
BE CURIOUS
BE PROFESSIONAL
BE ON TIME
-----------------------------------------------------------------------------------------------------------------TO BE COMPLETE BY THE PROSPECTIVE FIELD SUPERVISOR:
Please complete the bottom portion of this form and return to student at the conclusion of the interview.
1. Name of the student interviewed: __________________________________________
2. Agency/Unit/Department: ________________________________________________
Address: ______________________________________________Zip_________
3. Name of Interviewer:
4. Place an X in one of the choices below:
_____ Yes, I agree to supervise this student during the 2005-06 school year.
_____ No, I will not be able to accept supervision of this student for the 2005-06 school year.
_______________________________ ____________________
Interviewer’s Signature
Phone Number
Date
Fax: ________________________
E-mail:
_____________
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